Basic Information
| Provider Information | |||||||||
| NPI: | 1497020846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVES GRAY | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 W BALTIMORE ST | ||||||||
| Address2: | SUITE 247 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212231558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437031400 | ||||||||
| FaxNumber: | 4437031499 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W BALTIMORE ST | ||||||||
| Address2: | SUITE 247 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212231558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437031400 | ||||||||
| FaxNumber: | 4437031499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2012 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D80230 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 383841200 | 05 | MD | MEDICAID |